Coordinating Benefits with OHI

TRICARE is the primary payer for active duty service members. For all other beneficiaries, TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements, the Indian Health Service, and other programs/plans as identified by the TRICARE Management Activity (TMA).
 
If you have OHI, you need to follow the OHI’s rules for filing claims and file the claim with them first. If there is an amount your OHI does not cover, you can file the claim with TRICARE for reimbursement. It is important to follow the requirements of your OHI. If your OHI denies a claim for failure to follow their rules, such as obtaining care without authorization or use of a non-network provider, TRICARE may also deny your claim.
 
Keep Humana Military and health care providers informed about your OHI so they can better coordinate your benefits and help ensure that there is no delay (or denial) in the payment of your claims.
       

Keeping your OHI Updated

It’s important to keep your OHI updated.  You can update your OHI by downloading the OHI Form.  You can also update your OHI online by visiting myTRICARE.com.
       

Pharmacy Claims (Processed by (ESI)

When using OHI, the OHI is the first payer for pharmacy coverage. You may then be eligible for full or partial reimbursement from TRICARE for out-of-pocket costs, including copayments. If you have OHI, you should use a retail pharmacy under your private insurer that is also in the TRICARE retail network to avoid paying the TRICARE non-network deductible. You may not use the mail order pharmacy if you have prescription drug coverage from OHI, unless the medication is not covered under the other plan, or unless you exceed the dollar limit of coverage under the other plan. When you have OHI, the rules of that insurer apply. You should call ESI at 1-877-363-1303 for specific instructions about filing pharmacy claims if you have OHI.
         

Balance Billing

A term used to describe when a provider bills a beneficiary for the difference between billed charges and the TRICARE allowable charge after TRICARE (and other health insurance) has paid everything it’s going to pay. Participating providers are prohibited from balance billing. Nonparticipating providers may charge up to 15 percent above the TRICARE allowable charge.
 
Timely Claims Filing Policy